Kenan SEVER, İsmail Cihan ÖZBEK, Ali KOCAİLİK, Devnan MANSUROĞLU

Hemodiyaliz amaçlı arteriyovenöz fistüllerde gelişen çalma sendromunun basınç kontrollü PTFE banding yöntemiyle tedavisi

Amaç: Geliştirdiğimiz distal yataktan basınç ölçülmesi ile kombine banding yönteminin orta dönemde fistül açıklığı ve klinik sonuçlara etkisi irdelendi. Çalışma planı: Ocak 2002 - Aralık 2009 yılları arasında klinik değerlendirme ve Doppler USG ile semptomatik çalma sendromu tanısı konulan ve arteriyel basınç kontrollü politetrafloroetilen (PTFE) banding yöntemi ile tedavi edilen 20 hastanın orta dönem sonuçları değerlendirildi. Tüm hastalarda anevrizmatik brakiyosefalik arteriyovenöz fistül (AVF) mevcuttu. Ameliyat sırasında fistül proksimalinden brakiyal arterden ve radiyal arterden basınç monitörize edilerek radiyal/ brakiyal indeks değerleri kaydedildi. Fistüller radiyal-brakiyal indeks alt sınırı 0.6 oluncaya kadar daraltıldı. Banding işleminde anevrizmatik segmenti tamamıyla kapsayacak uzunlukta PTFE greft kullanıldı. Hastalar ameliyat sonrası dönemde 1. ay içerisinde ve daha sonra üç aylık periyotlarla kontrole çağrıldı. Kontrollerde fistül açıklığı ve semptomlar değerlendirildi ve kaydedildi.Bulgular: Üç hastada 1. ay sonunda yapılan kontrolde semptomlarda hafifleme görülmedi. Bu hastalara rebanding yapıldı. Diğer hastalarda erken ve geç komplikasyon gelişmedi. Tüm hastalar erken dönemde hemodiyalize girebildi ve semptomlar düzeldi. Birinci yılın sonunda, rebanding yapılan iki hasta dışında tromboz saptanmadı.Sonuç: Arteriyovenöz fistül sonrası gelişen çalma sendromunun cerrahi tedavisinde uygulanan başlıca cerrahi yöntemler distal revaskülarizasyon-interval ligasyon, banding, T-banding, greft interpozisyonu ve AVF ligasyonudur. Bu tedavi yöntemlerinin uygulandığı geniş cerrahi çalışmalar yoktur. Banding yöntemi teknik olarak kolay bir yöntem olmakla birlikte yetersiz banding çalma sendromunun devamına, gereğinden fazla daraltmalar ise tromboza neden olmaktadır. Çalışmamızda bir yıllık patens ve tromboz oranları sırasıyla %90 ve %10, semptomlarda düzelme oranı ise %95 olarak saptandı. Brakiyal ve radiyal arter basınç monitörizasyonu ile birlikte yapılan kontrollü bandingin fistül trombozu riskini ve yetersiz daraltmalara bağlı yeni girişimleri azalttığını düşünüyoruz.

Treatment of dialysis access-associated steal syndrome with pressure monitorization-assisted PTFE bandingİ

Background: We evaluated the mid-term effects on the fistula patency and clinical results of our technique of banding combined with pressure measurement from the distal bed. Methods: The mid-term results of 20 patients who were diagnosed with symptomatic steal syndrome by clinical and Doppler USG evaluation and treated with arterially pressure monitorized polytetrafluoroethylene (PTFE) banding method between January 2002 - December 2009 were studied. All the patients had aneurysmatic brachiocephalic arteriovenous fistula (AVF). Peroperatively, blood pressure was monitorized from the proximal of the fistula, brachial artery and radial artery and the radial/ brachial index values were recorded. Fistulas were constricted until the lower treshold of the radial-brachial index became 0.6. For the banding procedure PTFE grafts long enough to completely cover the aneurysmatic segment were used. Postoperatively, patients were asked to return for follow-ups within the 1st month and at three-month intervals thereafter. The fistula patency and the symptoms were evaluated and recorded in the follow-ups.Results: Symptoms were not alleviated in three patients at the 1st month follow-up. These patients underwent rebanding. In the remaining patients no early or late complications developed. All patients could receive hemodialysis in the early period and the symptoms were resolved. Other than the two patients who underwent rebanding, no cases of thrombosis were detected at the end of the first year.Conclusion: The main surgical procedures for surgical treatment of post-AVF steal syndrome are distal revascularization-interval ligation, banding, T-banding, graft interpositioning and AVF ligation. There are no large surgery studies involving patients treated with these methods. While banding procedure is technically easy, insufficient banding causes perpetuation of steal syndrome and more than necessary constriction causes thrombosis. In this study one year patency and thrombosis rates were 90% and 10%, respectively and the rate of relief of symptoms was 95%. We think that controlled banding with brachial and radial artery pressure monitoring reduces risk of fistula thrombosis and repeat procedures for insufficient constructions.

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